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        <p><strong>模块18：高级探诊技术(Advanced Probing Techniques)<br>Section1:牙周附着系统(The Periodontal Attachment System)</strong><br>健康牙周的附着系统<br>牙周附着系统是将牙齿固定于颌骨中的一组结构。为了留存在口腔内，每颗牙齿必须附着于：<br>①结合上皮(Junctional epithelium)——将牙龈附着于牙齿的上皮。<br>②牙龈纤维(Fibers of the gingiva)——环绕游离龈在牙齿周围并将游离龈与牙齿根面和牙槽骨连接在一起的纤维网络。<br>③牙周韧带纤维(Periodontal ligament fibers)——围绕牙根的纤维。这些纤维附着在牙槽窝内并附着于牙根的牙骨质上。<br>④牙槽骨(Alveolar bone)——围绕牙根的骨骼。它形成支持和保护牙根的牙槽窝。<br>附着丧失疾病<br>附着丧失是牙齿支持结构的破坏。发生在牙周组织的附着丧失根据其特点分为：①结合上皮的根方移位；②牙龈纤维的破坏；③牙周膜韧带的破坏；④牙周牙槽骨的丧失。<br>牙周支持系统健康与疾病状态的对比<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/01.png"><br><strong>Section2:用有刻度的探针进行评估(Assessments with Calibrated Probes)</strong><br>完整的牙周评估(Comprehensive Periodontal Assessment)<br>是用于收集牙周组织信息的完整全面的临床评估。通常包括临床特征如探诊深度测量，探诊出血，牙周分泌物检查，游离龈缘水平和膜龈联合水平，牙齿松动度，根分叉病变，牙石的存在，以及菌斑生物膜的存在，牙龈感染，牙槽骨丧失的影像学证据，以及局部促进因素的存在。这些信息的收集常需要使用牙周探针。<br>在全面牙周评估中牙周探针的作用见下表<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/02.png"><br>测量口腔偏移(Measuring oral Deviations)<br>有刻度的探针用来测量口内缺损或移位。<br>当在口内观察到病损时，发现应该被记录。以下信息应该被记录：①日期；②大小；③位置；④颜色；⑤病损的性质；⑥任何患者提供的信息（持续时间，感觉，或口腔习惯）。<br>最好使用解剖参考，而不是“长度”或“宽度”来记录你的发现。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/03.png"><br>评估牙齿动度<br>动度(Mobility）是牙齿在牙槽窝内的移动。是由于牙齿周围牙槽骨丧失导致的。<br>①水平向牙齿移动：是牙齿颊舌向的移动。<br>A.水平移动通过将两个牙科器械的柄部放置在牙齿的两面，使用颊舌向的运动的力量来评估。临床上常用钝的探针的柄或口镜柄来检查。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/04.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/05.png"><br>B.松动度可以通过使用邻牙作为参考点移动牙齿进行检查。<br>②垂直松动度——是牙齿在牙槽窝内下沉的能力——通过使用一个牙科器械的末端在咬合面或切端施加压力来检查。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/06.png"><br>③尽管牙周韧带允许牙齿在牙槽窝内有一些轻微的动度，但这种动度很小，不能被裸眼看出来。因此，当用视觉评估动度的时候，医生应该预期在牙周健康牙齿中看不到动度的。记住正常牙齿有0.5mm的生理动度。这种生理动度并不需要被记录在病历中。<br>④有很多记录松动度的分级方法。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/07.png"><br>评估探诊出血<br>轻微探诊时牙周袋的软组织的出血叫探诊出血，提示袋有溃疡(ulcerated)(例如，结合上皮的某些部分被破坏）。轻微探诊时出血是牙龈炎症的一个临床表现。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/08.png"><br>出血可以在探诊后立即出现，也可以有轻微的延迟。一个敏锐的检查者应该在每个位点停留数秒后再移动到下一个位点。<br>测量游离龈的水平<br>①牙龈缘水平与釉牙骨质界的相对关系。<br>②牙龈缘水平的改变。游离龈缘水平随着时间可能发生改变，作为对外伤，医疗或疾病的回应。龈缘和CEJ的关系有三种情况：<br>A.牙龈缘在CEJ的稍偏冠方。这是牙龈缘的自然位置，代表在没有疾病和外伤存在的情况下牙龈缘的位置。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/09.png"><br>B.牙龈缘完全覆盖CEJ。原因有两个：(1)肿胀；(2)由于某些药物导致的牙龈组织增生；(3)由于长期炎症导致的牙龈结缔组织的增生。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/10.png"><br>C.牙龈缘明显在CEJ根方。部分根面暴露。即牙龈缘退缩(recessiong of the gingival margin)<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/11.png"><br>③测量游离龈。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/12.png"><br>测量牙龈缘水平的技术：当组织肿胀或退缩发生时，用牙周探针来测量牙龈缘根方或冠方相对cej移位的距离。记住健康牙龈的牙龈缘位置是在CEJ稍微偏冠方。（1）对于牙龈退缩：用牙周探针探查CEJ和牙龈缘的距离。这个距离被记录为牙龈缘水平。（2）对于牙龈增生：用牙周探针测量cej到牙龈缘的距离，这个距离用下列技术来估计：a.与牙齿表面成45°角放置探针尖。b.沿着牙龈缘慢慢移动探针尖直到探查到釉牙骨质界。c.测量牙龈缘到cej的距离。这个距离即牙龈缘水平。<br>④记录牙龈缘水平<br>即GM，用+-和数值来表示。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/13.png"><br><strong>Section 3:通过计算来评估（Assessments that require Calculations)</strong><br>最常见的需要通过计算来评估的结果是临床附着水平(CAL)和附着龈宽度(width of the attached gingiva)。<br>CAL<br>为评估牙齿的稳定性和牙槽骨的丧失提供依据。CAL是已经被破坏的牙周支持组织的范围。CAL是比探诊深度更加准确的评估指标。探诊深度是从龈缘到沟底或袋底的距离，而龈缘的位置会因组织肿胀，增生，退缩而改变。因此探诊深度并不准确。CAL提供了一个更加准确的指标。它从一个牙面上的固定点（如，CEJ）开始计算。有附着丧失的存在是区分牙龈缘和牙周炎的关键因素。<br>因此探诊深度不能单独作为牙周支持组织数量的可靠指标。CAL是评估牙周支持组织数量的更好和更准确的指标。<br>测量和计算方法：分别测量CEJ到袋底的深度和龈缘的位置（相对CEJ），并记录到表里。龈缘位置用0(正好在CEJ位置），-（在CEJ冠方），+（在CEJ根方）和数值来记录。<br>CAL=探诊深度+龈缘位置。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/14.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/15.png"><br>附着龈宽度<br>是指在牙根颈部1/3(cervical-third)或牙槽骨的骨膜（结缔组织覆盖）牢固连接的那部分牙龈。附着龈在游离龈和黏骨膜之间，从龈沟（或牙周袋）基底扩展到膜龈联合。黏骨膜(alveolar mucosa)可以从视觉上通过其深红色和粉红的外观看出来。<br>附着龈的功能是保持游离龈不被从牙齿表面剥脱，保护牙龈免受创伤。不能从腭侧来测量附着龈宽度，因为难以分辨。附着龈不包括任何被牙体的裂隙，龈沟或牙周袋分隔的部分。<br>牙齿表面的附着龈宽度是牙医在进行很多修复治疗计划时必须留意的一个临床特征。如果牙齿表面没有附着龈，牙医进行修复的选择会有很多限制。因此，收集和计算附着龈宽度的信息很重要。<br>计算方法<br>所需要的信息已经在前面被记录了。第一步：测量从龈缘到膜龈联合的宽度。第二步，测量探诊深度。第三步，附着龈宽度=总的宽度-探诊深度。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/16.png"><br><strong>Section4:用根分叉探针进行评估(Assessments with Furcation Probes)</strong><br>根分叉是多根牙牙根分叉的区域。多数磨牙和部分前磨牙有根分叉。根分叉分为两根分叉(bifurcation)和三根分叉(trifurcation)。根分叉区域是在两个或多个牙根之间的区域。多根牙从CEJ到根分叉之间的区域叫根干(root trunk)。根分叉起始部位距CEJ大约3-4mm。 在健康的牙周组织中根分叉区域无法探查到，因为有牙槽骨覆盖。<br>下颌磨牙常常是双根，颊舌侧都有可能发生根分叉病变；上颌磨牙常为三根，颊侧，近中和远中都有可能发生根分叉病变。根分叉病变常是需要牙周手术的信号。<br>根分叉病变的影像学表现<br>统计显示上颌磨牙根分叉病变的发生率要三倍于下颌磨牙。很多有根分叉病变的磨牙能正常行使功能5-24年。上颌磨牙更容易在影像学检查中被发现，而不是在临床检查中。而下颌磨牙正好相反。<br>当观察上颌磨牙的根尖片时，一个小的，三角形的影像学暗影围绕在根分叉周围，有时超过近中或远中邻近根分叉区域。这些小的三角形影像学暗影被称为根分叉箭头(furcation arrows)。因为在未受累的根分叉中很少出现这种影像，所以根分叉箭头提示有分叉区骨破坏。然而，没有根分叉箭头出现并不意味着没有根分叉区骨破坏。一个三角形放射低密影在根分叉区域提示根分叉有病变。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/17.png"><br>根分叉探针的设计（略了，没那玩样儿，有牙周探针都不错了！）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/18.png"><br>根分叉病变分度<br>一度：可以用探针尖感觉到根分叉上方的牙面弯曲弧度，但是探针能伸入根分叉不超过1mm。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/19.png"><br>二度：探针可以进入根分叉超过1mm——大约扩展到牙齿宽度的1/3——但不能完全通过根分叉区域。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/20.png"><br>三度：在下颌磨牙，探针能够通过近远中根之间。在上颌磨牙，探针可以完全通过近中颊根和远中颊根之间并接触到腭根。（可见我们学的教科书上的说法只是指下颌磨牙。）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/21.png"><br>四度：与三度类似，只是可以直视根分叉贯穿全长。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/22.png"><br><strong>Section5:技能应用(Skill Application)</strong><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0113-yxgzjc27/23.png"><br>A. 探诊深度 6, 牙龈缘位置 0， CAL 6<br>B. 探诊深度 3, 牙龈缘位置3， CAL 3<br>C. 探诊深度 9, 牙龈缘位置-3，CAL 6<br>(总结：介绍了用探针进行一些牙周健康评估的方法，如探诊出血，牙龈缘位置，松动度，附着丧失程度，附着龈宽度等临床信息，这些都是要填到牙周大表里的信息。）</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“好看”。谢谢。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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